Sunday, August 30, 2009

Why we need health care reform

Fee-for-service penalizes evidence-based care. Check out this story, highlighting evidence-based practices at Utah hospitals and discussing the success of one hospital system's restrictions on early induction:

[D]octors and nurses resisted the new guidelines. From their vantage point, it was hard to see a problematic pattern, according to an Intermountain study published in the journal Obstetrics & Gynecology in April.

This made sense, considering that if an obstetrician performs 200 deliveries a year -- and 10 percent of his or her patients are electively delivered at 38 weeks -- statistics show only one baby would be admitted to the neonatal intensive care unit (NICU) each year.

When Intermountain analyzed nearly 180,000 births, however, the data were startlingly clear: For babies born at 37 weeks, the incidence of severe respiratory-distress syndrome was 22.5 times higher than those born at 39 to 41 weeks. At 38 weeks, it was still 7.5 times higher. Other problems, such as pulmonary hypertension, admission to the NICU and hospital stays beyond five days, were also more likely.

"If no one ever gives you the scientific data to drive your decisions, you can be pretty comfortable not doing best practice. You just don't know," said Janie Wilson, operations director of Women and Newborn Clinical Programs, which in 2001 developed a program to curtail early-term deliveries. ...

Within six months of the initiative... the rate of early-elective deliveries at Intermountain hospitals dropped to 10 percent from 28 percent; eight years later, that number is less than 3 percent.

But something else happened, too: Intermountain lost money. By performing fewer early-term elective deliveries, the health system saw shorter lengths of stay. NICU admissions dropped. Patients received fewer lab tests, antibiotics and Caesarean-section surgeries.

"The bottom line to our cost was significant," Wilson said.

An analysis of the impact on the health system revealed it lost $3.3 million in net revenue between 2001 and 2005. And that was a conservative estimate, based only on length of stay in labor and delivery, Wilson said.

To have a profit-driven system, you don't have to have individual providers rubbing their hands together, cackling gleefully over all the extra money they're going to make with early elective inductions. Everyone can intend the best for mothers and babies, but the incentives just aren't there to take a closer look at the evidence. And when the evidence comes up on the side of fewer reimbursements, that's one less argument you can use to make your case. Health care reform that rewards evidence-based care and de-emphasizes fee-for-service can change that.

Friday, August 28, 2009

Journey to IBCLC begins!

I had my first class today for my IBCLC training. So excited! I will have 6 hours observation with the LCs in the hospital Wednesdays, 2 hours of lecture on Fridays, and need to find 2 more hours each week somewhere for observation - either LLL meetings, working with private LCs, or extending my hospital day. First semester we'll be focusing on supporting normal breastfeeding with healthy term infants, and doing mostly observation. Second semester we will move into special situations, and be more hands on. I think the long observation period will be great for me - reminding me to step back, stay quiet, look and listen. It was also a relief to hear the first lecture from one of our professors, who said "Your ideal this year is to do nothing" and talked about the dangers of overmedicalizing breastfeeding, and how to support moms by focusing on what they are doing right, and supporting them to make their own decisions about what to change.

One thing I realized while looking at my schedule is that it will be difficult for me to work with anyone more than once, and get experience with managing a case over time. Hopefully next semester, when my schedule is more flexible, I can make arrangements for at least a couple of weeks to work sets of shorter hours with an LC who does longer-term follow-up.

In the meantime, my textbook is on its way and my first observation hours are next week! I have to remind myself that even though I am going to be crazy busy this semester, I am lucky to have the things that are making me busy (classes for my MPH degree, my assistantship that is funding my tuition, an hours to become an LC). I don't want to feel stressed or resentful, when in truth I am so fortunate.

ACOG collects data on "unsuccessful" home births?

I got an e-mail on a doula listserv today that ACOG had a survey up on their website asking for anonymous data from OBs on "unsuccessful home births". The e-mail I got was encouraging mothers to go over there and fill it out with their successful home birth experiences. One woman replied saying she'd done one for each of her six home births! By the time I clicked over, ACOG had clearly realized their mistake and put it behind a members-only log-in section.

Here's the data they were collecting, according to the e-mail I got:

Month and year of delivery
Maternal Age
Gestational Age
Fetal Outcome
Pre-Arrival length of labor
Home Attendant

This is disturbing to me becaue it suggests that ACOG is willingly engaging in the game of "Birth Telephone" - encouraging anonymous stories with no way confirm or deny the allegations. It also suggests that rather than debate recent, and strong, research evidence showing planned home birth can be as safe as hospital birth, they'd rather collect these anecdotes as...what? "Proof" for their side? Fuel for the fire? Where is this "data" going?

Wednesday, August 26, 2009

When should you call in the breastfeeding cavalry?

When I worked in a store fitting nursing bras, a lot of women came in at their 8th or 9th month to get a few bras to start with. It was a boutique-type place, so I'd spend time with them fitting numerous bras, helping them find nursing clothing they might like, and setting them up with pumps or other needs they wanted to take care of.

As I spent time with each woman, I would try to start a conversation with her about breastfeeding. And I can't tell you how many women said "I'll give it a try" or didn't want to buy too much "In case it doesn't work".

I will readily admit that breastfeeding does not work out 100% of the time. There are women who are physiologically unable to produce enough milk. There are babies who have physical or birth trauma-related issues that make it difficult or impossible to nurse. It's times like this that everyone is grateful for alternate feeding methods and the substitute foods of donated breast milk and/or formula. But I tried to emphasize to these women how rarely these situations ACTUALLY happen. I read a study a while back in which only 5% of women referred to a lactation clinic for insufficient milk supply turned out to be physiologically incapable of producing enough milk. The stories they've heard about insufficient milk supply or babies who refuse to latch are probably, 95% of the time, due to poor management and lack of support.

And that's why the store pushed a piece of paper into everyone's hands with the times and locations of support groups, and contact info for IBCLCs the owner knew and liked. I would hand this paper over telling them to call if they had a problem and repeating a mantra of "Call early, call early, call early". When a newly postpartum woman came in, and made that little grimace when I asked how breastfeeding was going, I put the piece of paper in her hands saying "Call today, call today, call today". Why? Because the longer you let things go on, the worse they get. The sore nipples become cracked, the baby who won't come off the breast starts to lose weight, the occasional bottle becomes regular. I drew the analogy of a road branching off to the side - the farther you travel down the wrong road, the harder it will be to get back on the right one. And newborns travel fast - so your baby is four days old and things have been going badly for the past day? That's a fourth of their life! Not to mention that those early days are when women's bodies are establishing their milk supply.

Here's a story about initial low milk supply where an LC, supportive pediatrician, and determined mom caught a problem fairly early and dealt with it. This is a story that could so easily have spiraled down into lower milk supply, panic, supplementation and the declaration that "some women just can't make enough milk". But it didn't - so call early, call early, call early!

Waterbirth with a doula, and race in the natural birth movement

Via Bellies and Babies:

I really liked hearing the doula in this video talk a little about the racial connotations that natural/unmedicated birth has in our country (I would venture to say class connotations are equally important). While several of the women shown giving birth in "The Business of Being Born" are women of color, in general the natural birth movement has been by and for white women.

I admit I am uncomfortable with the way this plays out in many situations. In AmeriCorps, my fellow doulas and myself were all young, white, native English speakers who had all grown up at least middle-class and attended college (and none of us had yet given birth ourselves). We were working with mostly low-income, Spanish-speaking Latina women. Do you need have the same background as a woman to be a good doula? Absolutely not, and we forged strong bonds with many of our clients. But the fact was that our AmeriCorps positions were not accessible many women from other backgrounds for a variety of reasons (the long hours and very low pay, a program that hired only college grads, and not a lot of resources for recruitment to ensure a diverse applicant pool).

In becoming an IBCLC, I will again be a white woman joining a mostly white profession...that aims to reach ALL women and help them to breastfeed. I would like to do some thinking in my doula and LC practice about how I can not only be more culturally competent myself (because it should never be the expectation that any individual is absolved from being able to work competently with the people they serve) but also take responsibility for the opportunities I've been given by encouraging more diversity in my professions. Our breastfeeding advocacy group is thinking about fundraising for a scholarship to help women from underrepresented groups access IBCLC training. I hope that will be a start.

Sunday, August 23, 2009

A subway car full of nursing moms

A New York State Senator and a subway car full of nursing moms took the A train recently in support of breastfeeding and the right to nurse in public:

State Senator Liz Krueger (D-Manhattan) joined the New York City Breastfeeding Promotion Leadership Committee (NYCBPLC) today for their annual Breastfeeding Subway Caravan. The Subway Caravan began in 2004 as a means to highlight the importance of breastfeeding and reinforce a women's right to breastfeed wherever they have a right to be. The focus of this year's Caravan is the passage of Senator Krueger's Breastfeeding Bill of Rights (S1674-D). The legislation codifies mothers' rights to breastfeed into a single, concise document and bans commercial interests from influencing new mothers' choice of breastfeeding.

I wish the last part referred to a ban on formula gift bags in hospitals, but it's just a right to refuse the gift bags - maybe to prevent women from being pressured to "just take it in case you need it". Read more on the Senator's website here.

Friday, August 21, 2009

More thoughts on IBCLC and lactation consulting

My excitement about becoming an IBCLC is mixed with a little apprehension. Given the amount of respect and the number of referrals I’ve given to LCs over the years, I've gotten to thinking about the responsibility of being a good one, the critiques I’ve heard of LCs (both individually and as a profession) over the years, and how I will negotiate that in my own training and eventual practice.

There’s a kind of LC I don’t want to be – the one who marches in grabs, yells, guilts, and blows back out. and I don’t think she exists nearly as often as she’s made out to – as MomTFH points out, they seem to be more creatures of story than of life – but still, I don't want to be one. I also worked in one city where stories circulated about a certain LC who discouraged bottle-feeding/formula supplementation to the point where other LCs were considering reporting her to ILCA. Clearly, I don't want to be her either.

My aspirations for the kind of LC I want to be are the same as for the kind of doula I want to be: meeting women where they're at, helping them determine what their goals and needs are, and going from there. The ultimate goal is a positive breastfeeding relationship for a healthy mom and baby – and if that means less breastmilk and more happiness, so be it.

The piece I really want to build in my own practice is active listening and slooooowing down. I am a "let's fix it now" kind of person. Being a doula, labor forces me to slow down: it can't be rushed, and laboring women definitely can't be hurried into anything ("How about you try moving before the next contraction? Already started? OK, we'll try after the next one...").

Other areas of life don't have those same built-in speed bumps. When doing breastfeeding consults, it's so easy to seize on the first problem you see/hear about, "fix" it, and walk out self-satisfied. I keep thinking back to breastfeeding consults I did in AmeriCorps - they were good experience, but I want to do better in the patience department (vs. Just get the baby to latch, explain how, ask "You understand, right?” and tell her I’ll call tomorrow.) We had no LCs in our health centers (ha! Would that we had money for “extras” like that) but the midwives did some breastfeeding support. I once spent 15 minutes with a mom, "fixed" all her problems, and sent her on her way. Still frustrated, she came back the next day and my supervisor, a wise and experienced midwife, spent 45 minutes just sitting and talking with her. Oh. Right. Listening. Later that year, I watched another experienced midwife do a breastfeeding "consult". I kept twitching internally at all the moments I would have jumped up and jumped in, and she just sat and watched the baby feed...and feed...and feed...and finally she said "You’re doing great, just make sure baby is eating frequently, see you later." When the family left, she said, "They're doing it differently than I would, but they're doing fine. The important thing is to give them confidence." Oh. Right. Empowerment.

And as I said in my comment to MomTFH's post, I think that some LC horror stories might come from a mother’s reluctance to say out loud "I want to quit" while the LC is barreling full steam ahead. I want to be able to make space for those discussions with the women I work with.

I think that "let's fix it now" attitude also contributes to the medicalization concerns I hear around LCs. I recognize and respect concerns many people have about LCs medicalizing and formalizing breastfeeding. My ideal for breastfeeding support is peer-to-peer; in a perfect world, women should have many friends, relatives, and neighbors who are experienced breastfeeding moms and can offer informal support. In a less ideal world, sometimes more formalized support comes in handy - and in special cases, sometimes it will always be necessary.

But just as maternity care providers shouldn't medicalize birth just because they can, neither should LCs over-intervene and technologize breastfeeding just because they have the tools to do it, and not enough time and patience to spend time listening and processing. (My pet peeve is nipple shields being handed out like candy for every problem under the sun, and mothers sent home with the baby, the nipple shield, and no support or follow-up. Grrrr.)

I also don't want to be the "hospital LC" who only knows newborns . In this course, most of our experience will be in the hospital, but we'll also have clinical hours in outside settings. I really want to use that time, and find other opportunities, to build up my knowledge of breastfeeding support past the first few weeks/months. I want to help women through complex and challenging situations – reading through Dou-la-la’s amazing story of overcoming breastfeeding challenges and her thanks to her IBCLC – I thought WOW, that’s what I’m talking about! I want to be there for women who have the determination and just need some support and assistance, and to do that, I have to know my stuff.

In birth plans people are rightly advised to state what they want more than what they DON’T want…let’s see if I can follow my own advice! So I want to be an LC who:
- Listens to and empowers women
- Provides support without judgment
- Uses and promotes evidence-based practices, erring on the side of less technology
- Understands a range of breastfeeding situations and issues, from premature infants through toddlers

I hope and believe that the LCs I'm working with will be good models for all of this. But I also realize I may feel the need more independent work on counseling techniques, reflective listening, etc. Does anyone have suggestions for this?

Also, I know this has been hugely long (I’ve been putting down more and more thoughts ever since I heard I might be able to take this course!) and mostly my own thoughts about lactation support. But if you’ve made it this far, I’d like to hear what has been good and bad about IBCLCs (or other lactation support professionals) that you have worked with in the past? What’s something you wish they knew, or would like to tell me to do/not do?

Back-to-school birth story

It's funny how life works. The year after high school I was a Rotary exchange student in Sweden, and Tralee was another exchange student in my district (she was from another part of the U.S.). We saw each other at various Rotary camps and weekends; she was always wickedly funny and kept all of us students laughing with her stories and (mis)adventures. Our common bonds were forged over a love of Swedish candy and the trials and tribulations of exchange student life.

After we came back to the U.S. Tralee and I kept in occasional touch and even managed to visit a couple times despite being on opposite coasts. The funny thing is that somehow over the past decade we have both independently come to a place where we are very involved in birth/breastfeeding - me through public health and doula work, and Tralee through her experience of becoming a mother and educating herself extensively. I saw her earlier this year when she was pregnant with her second and planning a home birth, and she's now posted her birth story. I love this quote:

To me birth is natural, not painful...yeah a little discomfort but every contraction was helping me, every moment was me experiencing me. I looked forward to each new phase, like a runner trains for a marathon...after so much prep and training you think ”yeah come on, bring it...bring on that hill, I can do this."

Congratulations to the Knapp family! I can't wait to see you guys again.

As for me, I'm back at school, getting ready for classes to start next week...including my lactation consultant course! I am excited and also a little nervous. More posts coming soon!

Monday, August 17, 2009

Posting hiatus & who else had a home birth

My posting is slow for the moment - I'm back in my hometown, visiting with family and friends, and taking a (too-short) vacation before school starts again. I can't believe in one week I'll be starting classes...this summer has flown by.

In the meantime, a friend tipped me to the fact that singer Goapele had a home birth and is encouraging her Twitter friends to support the MAMA campaign: "Having a natural home birth was one of my most empowering experiences. Please support midwives."


Here comes my aunt and to the lake to swim and beat the heat!

Tuesday, August 4, 2009

Gimme an I! B! C! L! C! IBCLC!

I have held off getting too excited (OK, I've gotten plenty excited, I've just held off posting) about the possibility of taking a course next year to become an International Board Certified Lactation Consultant (IBCLC). Now it looks like it will happen and I am so excited!

I’m especially happy to post about it knowing many of you will “get” my excitement. It’s hard to convey to non-birth/breastfeeding people what a big deal this is – both the credential in general, and to me personally. If there’s one thing I love as much as attending births it’s working with breastfeeding dyads (although I haven’t gotten to do it in a long time). I’ve thought about going for the IBCLC before, but counted it out (at least for the time being) for a variety of reasons. The chance to get it as part of my MPH is stunning and amazing.

It will be a one-year course under Pathway 2 - one full day of training and clinical rounds each week at the hospital, plus weekly hours in other settings (La Leche meetings, WIC, etc.), plus readings and assignments. If all goes as planned I will finish my MPH in May and sit for the IBCLC exam in July. While I’m not really sure where I will go with it after graduation, it would be great if, combined with my MPH, it ups my chances of getting a job working with breastfeeding/perinatal issues. I also wouldn’t complain if I was “just” an LC somewhere for a while!

I have more posts coming, about my thoughts about lactation consulting as a profession, negotiating concerns around medicalization of breastfeeding, etc. But right now I'll just take a deep breath and look forward what promises to be a very busy school year.

Monday, August 3, 2009

Jennifer Block on who's winning the home birth debate

New article from Jennifer Block on Who's Winning the Home Birth Debate. It's a step beyond the usual "Hey, home birth might be safe" or "Some people say home birth is safe" articles and into "If research has shown that home birth is safe, why is there still so much opposition?" She writes:

if the only research that will satisfy those with authority and power is research that is unfeasible, the controversy will never be resolved. There could be 20 more large, observational studies that come to the same conclusion as those that already exist, but they still wouldn't be randomized controlled trials. The home birth advocates would continue to say "The research proves it's safe!" and the American medical establishment would continue to say "The research isn't good enough!"

And, as she points out, evidence of homebirth dangers will continue to be produced via anecdote and rounds of "birth telephone".

If anything, I could have done with this article being a lot longer. I liked that she acknowledged the presence of the (in)famous Dr. Amy and Dr. Amy's "debate" site, and I'd like to see her really dig into the statistical discussion, the evidence base, and the depth and breadth of the barriers to translating evidence into practice. Perhaps you'd like to write another book, Jennifer Block?

In the meantime, props to Babble. At a wedding a few weeks ago, I ran into someone I know who works there and I told her I really liked Jennifer Block's response to Hanna Rosin, which they ran. Next time I see her I'll have to add my thanks for this. I hope they keep up the Jennifer Block connection, or at least keep running articles in this vein.

Saturday, August 1, 2009

Cesarean vs. VBAC

Via The Unnecesarean, who says "Alexandra Orchard is my personal hero":

Cesarean vs. VBAC: A Dramatic Difference from Alexandra Orchard on Vimeo.

While there are a lot of things I loved about this video (the honest portrayal of cesarean surgery, for one), the letter is what really blows me away. I would love it if more women who are disappointed with their care providers and hospitals openly expressed that disappointment. Nothing is going to change without better communication and who better to speak than someone speaking from immediate personal experience? It's hard for doulas to push that too much with individual clients, but it is inspiring when women and their families take the lead.